Doctors develop practice for delivering bad news

September 06, 2006|STEPHANIE BEASLEY The Baltimore Sun

When her partner, Mickey Barron, was diagnosed with breast cancer in 2001, Dr. Rhonda Fishel accompanied her to the oncologist's office. As an experienced surgeon, Fishel was no stranger to the delivery of bad news. She was the one who jotted notes furiously as the doctor discussed treatment options, while Barron's mind struggled just to get past the word "cancer." "He was going on about treatments, and I was gone," Barron recalled. "I was too stressed out." Four years later, when Fishel was diagnosed with a rare cancer called uterine sarcoma, it was Barron's turn to listen carefully as her partner sat numbly. "I never understood what it felt like physically, until I had to go through it. It's like a pain in your chest," said Fishel, 51, who has reduced her hours as associate chief of surgery at Sinai Hospital in Baltimore and director of its intensive care unit since being diagnosed and treated. Fishel is convinced that patients often remember more about how their doctor broke bad news than they do about their diagnosis. "You go into these rooms knowing that you're going to destroy people's lives," Fishel said. Yet she has heard of colleagues who deliver bad news from the doorway of a patient's hospital room and then quickly back out. It's a concern shared by other physicians who have developed a protocol for delivering news that they know will be devastating. "It acknowledges the fact that giving bad news is very hard and doctors aren't taught those skills," said Dr. Walter Baile, chief of psychiatry at the MD Anderson Cancer Center in Houston. Known as SPIKES, which stands for "Setting, Perception, Invitation, Knowledge, Empathy and Strategy/summary," it emphasizes skills that Baile says are useful for physicians who have to deliver bad news. As part of the six-step process, Baile says, physicians should take their time when delivering news to ensure that patients understand what is being said. Too many doctors, he says, toss too much medical terminology at their patients. Baile said it's also critical to choose a location that's comfortable for the patient and to pay attention to the patient's emotions as he receives the information. "The most important thing is to make an empathetic statement, to say something like, 'I can see that you weren't expecting bad news,' or 'wish' statements like, 'I wish there was something I could do.' That's very different from saying, 'There's nothing I can do,' because that's abandonment," he added. Fishel relies heavily on the SPIKES philosophy in a presentation she gives to young doctors and medical students titled, "Giving and Receiving Bad News: Lessons I've Learned." Fishel learned of SPIKES from a friend -- an oncologist using it with her own patients. Fishel developed her talk after a nephew in medical school asked her to speak to his class last summer. Having received her own cancer diagnosis by this time, she decided to develop something more substantive than the usual jargon-filled lecture accompanied by the gory pictures that medical students love. "I thought a more relevant talk for young, upcoming physicians was bad news," she said. Here she parts company with Baile, who said he's reluctant to give presentations to young medical students who don't have the experience to put SPIKES into context. "If you teach it too early in the medical career, before they've had patients, it really doesn't make much sense to them. I think that students can learn it, but whether they retain it is the question," Baile said. Jay Bhatt, president of the American Medical Student Association, disagreed. "I don't think that it's ever too soon to understand human interactions, human emotions and how that impacts people's health," he said. At the University of Maryland School of Medicine, Douglas Ross, an oncologist and professor who specializes in hospice care, says students are introduced to end-of-life issues within the first two years of their program. They begin visiting hospices during the junior year through a program funded by the National Cancer Institute. However, they are not formally trained to use processes such as SPIKES until they are residents. "Our philosophy is that the medical students will often be taught by the residents, and we will not graduate residents unless they complete this training," Ross said. When she spoke to her nephew's class at the Kirksville (Missouri) College of Osteopathic Medicine, Fishel said that the medical students were interested in hearing her advice on delivering bad news. "The response was incredible," she said. Two weeks ago she brought the presentation home to an audience of nearly 100 in Sinai's Zamoiski Auditorium. The message combined humor, personal anecdotes and stories involving some of her breast cancer patients who have recovered from hearing the bad news and are leading full lives. After months of chemotherapy, Fishel's cancer is in remission. Likewise for her partner, Barron, 51, a nurse practitioner. "People would make plans like 'Can you give this talk?' And I'm (saying), like 'Well if I'm alive,' " Fishel recalled. "Now I have my energy back, which is one of the best things that you can have. I find myself using words like 'grateful.' "